Rare Pediatric Cecal Anomalies: A Lesson in Pediatric Surgery.

BACKGROUND: Rare incidence cases are part of the routine work of pediatric surgeons. Cecal anomalies in children are an example of such cases. Objectives: To describe the presentation, workup, management and outcome of rare cecal anomalies in children and to analyze the skills needed for their successful treatment. METHODS: A retrospective chart review was conducted of all cases of cecal anomalies managed by the pediatric surgical service at a tertiary hospital from June 2017 to January 2020. Data regarding demographics, clinical presentation, radiological studies, surgical treatment, pathology, complications, and outcome were collected. RESULTS: Five cases of cecal anomalies were encountered over a period of 32 months, including a cecal volvulus, cecal duplication, cecal intussusception, and two cecal masses (one ulcerated lipoma and one polyp). All patients, except the patient with cecal duplication, presented acutely and were managed surgically. Long-term follow-up of 17-24 months was unremarkable in all cases. CONCLUSIONS: A wide knowledge base, careful judgment, and creativity enable pediatric surgeons to successfully treat rare conditions such as rare cecal anomalies. These skills should be part of the education of pediatric surgery trainees.

[A Case of Appendiceal Intussusception Induced by Early Appendiceal Carcinoma].

Appendiceal intussusception is an uncommon pathologic condition. We report herein a case of appendiceal intussusception induced by appendiceal carcinoma. A 76-year-old woman was admitted to hospital because of epigastric pain. CT scan showed multiple concentric ring sign in ascending colon and enhanced tumor in transverse colon. Colonoscopy showed invagination of polypoid lesion which was pushed back to cecum endoscopically. Laparoscopy-assisted ileocecal resection with regional lymph node dissection was performed for cecal cancer. During surgery, the appendix was found to be inverted completely into the cecum. The tumor was 70×35 mm in size in the cecal cavity, and the appendix had completely invaginated into the cecum at its base. Histopathologic examination revealed early appendiceal carcinoma. The patient is healthy without recurrence.

What are the predictive factors of caecal perforation in patients with obstructing distal colon cancer?

AIM: In the presence of large bowel obstruction, the choice of treatment is determined by the patient's general status, the tumour characteristics and the perceived risk of caecal perforation. This study was designed to evaluate the predictive factors of impending caecal perforation, and also investigated the use of caecal volumetry. METHOD: From January 2011 to June 2016, patients with obstructive distal colon cancer undergoing emergency laparotomy, for whom a pretreatment CT scan was available, were included in this retrospective, case-control, two-centre study. Two patient groups were defined: patients with and without impending caecal perforation. The primary end-point of the study was a determination of predictive factors for caecal perforation. RESULTS: A total of 72 patients (45 men, 62.5%) were included. Univariate analysis revealed that the presence of pericaecal fluid (P < 0.0001), caecal pneumatosis (P < 0.0001), mean maximum caecal diameter (P = 0.001), mean caecal diameter at the ileocaecal junction (P = 0.0001) and mean caecal volume (P = 0.001) were associated with caecal perforation. Receiver operating characteristic curve analysis revealed that a caecal volume greater than 400 cm3 (P < 0.0001), a maximum caecal diameter > 9 cm (P = 0.002) and a caecal diameter at the ileocaecal junction > 7.5 cm (P = 0.001) were associated with impending caecal perforation. In multivariate analysis, only caecal volume > 400 cm3 (P = 0.001) was correlated with the risk of impending caecal perforation. CONCLUSION: Caecal volumetry is an easy and useful tool to predict impending caecal perforation in patients with large bowel obstruction.

Ileocecal endometriosis as an infrequent cause of intussusception.

We present a case of ileocecal endometriosis as a cause of infrequent ileocolic intussusception in an adult patient. It is reviewed as published by the authors Sanchez Cifuentes, A et al. 2016, emphasizing the rarity of the location of endometriosis, and its association as a cause of intussusception.

Cecal perforation: A rare complication of a ventriculoperitoneal shunt.

Hydrocephalus can be the result of an infection, obstruction, impaired reabsorption of cerebrospinal fluid (CSF), or an abnormal increase in CSF. Ventriculoperitoneal (VP) shunting is the gold standard treatment for hydrocephalus despite its high rate of complications, including catheter obstruction and infection. Spontaneous cecal perforation by a VP shunt is extremely rare. Headache or subtle change in personality may indicate a VP shunt infection. Early recognition of the infection is critical for optimal patient outcomes.

Intestinal obstruction secondary to cecal endometriosis.

Endometriosis of the gastrointestinal tract is rare and occurs in <1% of all patients undergoing major gynecological surgeries. Bowel involvement has been reported in 3%-37% of all women of childbearing age with endometriosis. Total obstruction of the gastrointestinal tract occurs in <1% of cases of endometriosis with bowel obstruction. This case report is that of a 42-year-old female who presented with a 6-month history of change in bowel habits in favor of increasing constipation. This was associated with cyclical lower abdominal pains, abdominal swelling, and weight loss. Examination revealed hyperactive bowel sounds with scant fecal matter on rectal examination. An impression of intestinal obstruction was made and she had an emergency laparotomy. Dilated ileum and a hard, constricting cecal mass were found intraoperatively. She had a right hemicolectomy and ileo-transverse anastomosis, with progressive improvement postoperatively. Histology of the resected bowel segment confirmed cecal endometriosis. In conclusion, cecal endometriosis is a rare cause of intestinal obstruction. A high index of suspicion is required for diagnosis, especially if the woman is premenopausal with a history of abdominal pain that worsens with menstrual periods. Outcome is good with appropriate surgical intervention.

Postoperative Complications after Ileocecal Resection in Crohn's Disease: A Prospective Study From the REMIND Group.

OBJECTIVES: We sought to determine the frequency of and risk factors for early (30-day) postoperative complications after ileocecal resection in a well-characterized, prospective cohort of Crohn's disease patients. METHODS: The REMIND group performed a nationwide study in 9 French university medical centers. Clinical-, biological-, surgical-, and treatment-related data on the 3 months before surgery were collected prospectively. Patients operated on between 1 September 2010 and 30 August 2014 were included. RESULTS: A total of 209 patients were included. The indication for ileocecal resection was stricturing disease in 109 (52%) cases, penetrating complications in 88 (42%), and medication-refractory inflammatory disease in 12 (6%). A two-stage procedure was performed in 33 (16%) patients. There were no postoperative deaths. Forty-three (21%) patients (23% of the patients with a one-stage procedure vs. 9% of those with a two-stage procedure, P=0.28) experienced a total of 54 early postoperative complications after a median time interval of 5 days (interquartile range, 4-12): intra-abdominal septic complications (n=38), extra-intestinal infections (n=10), and hemorrhage (n=6). Eighteen complications (33%) were severe (Dindo-Clavien III-IV). Reoperation was necessary in 14 (7%) patients, and secondary stomy was performed in 8 (4.5%). In a multivariate analysis, corticosteroid treatment in the 4 weeks before surgery was significantly associated with an elevated postoperative complication rate (odds ratio (95% confidence interval)=2.69 (1.15-6.29); P=0.022). Neither preoperative exposure to anti-tumor necrosis factor (TNF) agents (n=93, 44%) nor trough serum anti-TNF levels were significant risk factors for postoperative complications. CONCLUSIONS: In this large, nationwide, prospective cohort, postoperative complications were observed after 21% of the ileocecal resections. Corticosteroid treatment in the 4 weeks before surgery was significantly associated with an elevated postoperative complication rate. In contrast, preoperative anti-TNF therapy (regardless of the serum level or the time interval between last administration and surgery) was not associated with an elevated risk of postoperative complications.

[A rare case of coecal volvulus after colonoskopy due to a mobile coekum - diagnosis, surgical therapy and postoperative complications]. / Ein seltener Fall eines Volvulus des Coecums nach Koloskopie bei Coecum mobile ­ Darstellung von Diagnostik, operativer Therapie und postoperativen Komplikationen.

Colonoscopy, either performed as screening or as a therapeutic proceedure, is, in general, very safe with only a few cases of serious complications. Most cases of bleeding after endoscopic polypectomy can be safely managed endoscopically. The rare cases of colonic perforations still have to be managed by surgical intervention. The postpolypectomy-coagulation syndrome and a cecal volvulus are very rare complicatoions after colonoscopy. In the current manuscript, we describe a rare case of a cecal volvulus after routine colonoscopy due to an unknown mobile coecum as a predisposition. We discuss the endoscopic, clinical and radiological findings of the patient. Moreover, we describe the performed surgical procedure and the further clinical course of the patient. A cecal volvulus should always be considered as a possible rare, but serious, complication in the differential diagnosis of abdominal pain after colonoscopy. The standard therapy of a cecal volvulus is the right hemicolectomy. As an alternative, a coecopexy without resection could be performed as long as the colonic wall is still vital.

Fistulizing nodular lymphoid hyperplasia.

BACKGROUND: Nodular lymphoid hyperplasia (NLH) of the gastrointestinal (GI) tract is a rare condition in adults. It is usually asymptomatic. Few complications have been described. AIM:   We report an unusual clinical presentation of focal lymphoid hyperplasia of the GI. CASE REPORT: A 23-year-old female patient presented with a fistulizingdisease of the terminal ileum and the caecum complicated with an abscess of the lower right quadrant if the abdomen. CT-guided drainage with antibiotic therapy failed to control the abscess. Thus, surgery was undertaken and ileocaecal resection was performed. Focal lymphoid hyperplasia was confirmed by the pathology of the specimen. CONCLUSIONS: NLH is an uncommon condition in adults. To the best of our knowledge, no previous cases have been reported with fistulizing NLH. The management should follow the same algorithm as fistulizing ileitis. Surgery is indicated only in cases of complicated disease after the failure of medical treatment.

A very rare case of a small bowel leiomyosarcoma leading to ileocaecal intussusception treated with a laparoscopic resection: a case report and a literature review.

BACKGROUND: Small bowel tumours are rare and comprise less than 2% of all primary gastrointestinal neoplasms. Among these tumours, a leiomyosarcoma belonging to soft tissue sarcomas is extremely rare and accounts for about 1 % of malignant mesenchymal lesions in the gastrointestinal tract. Due to its aggressive nature and slow growth, it is often diagnosed at the late stage when curative treatment is impossible. Authors report a first case of leiomyosarcoma with chronic recurrent ileocaecal intussusception and literature review to analyse diagnosis and treatment features of the ileum mesenchymal tumours. CASE PRESENTATION: We present a case of an 87-year-old Caucasian man suffering from cramp-like abdominal pain for months. Due to lack of clinical signs and unspecific complaints, a diagnosis was delayed. Despite a detailed in-hospital examination, a proper diagnosis was established as late as during an operation. The patient was treated by surgery with good results. An uncommon laparoscopic resection of the small bowel with a tumour was performed. A histopathological investigation confirmed a very rare mesenchymal lesion of the distal ileum. The patient is under control with no recurrence for 1 year of the follow-up period. CONCLUSIONS: Reported case indicates that a usually asymptomatic tumour can cause uncommon chronic recurrent ileus signs. CT and MRI scans are investigation of choice in such cases, but they are sometimes inconclusive. It might be worth highlighting the good results of laparoscopic leiomyosarcoma lesion resection with a very good outcome.

[A Case of Mantle Cell Lymphoma Diagnosed after Surgery for Ileocecal Intussusception].

A 63-year-old woman visited our hospital complaining of abdominal pain and bloody discharge in November 2015. Abdominal CT revealed ileocecal intussusception. After hospitalization, a right colectomy was performed. Pathological diagnosis of the resected specimen was Mantle cell lymphoma. After this diagnosis, chemotherapy was initially administered. Following this, peripheral stem cell transplantation was carried out. We discovered this case of Mantle cell lymphoma by chance; therefore, here, we consider and introduce how this type of disease should be treated. We also introduce a rare case of Mantle cell lymphoma with intussusception at the cecum.

Small bowel obstruction caused by Anisakis and Meckel's diverticulum: a rare case.

INTRODUCTION: Anisakiasis is a parasitic infection caused by the ingestion of raw fish contaminated by larval nematodes of Anisakis species. Intestinal or extraintestinal manifestations are rated to > 4% and >1% respectively. PRESENTATION OF CASE: A 61-year old patient was admitted to our General Surgical and Emergency Unit because of sudden abdominal pain, vomit and constipation. He had eaten raw fish 3 days before admission. Laboratory data showed high levels of WBC and PCR. CT scanning showed "dilation of jejunum and ileum loops, thickening of the terminal ileum and cecum and signs of inflammation of the intestinal wall and mesentery". The following emergency surgical procedure was performed: laparotomy with evidence of obstruction of the small bowels, a giant Meckel's diverticulum, resection of terminal ileum and cecum and ileocolonic anastomosis. At the microscopic examination, the intestinal wall appeared occupied by a transmural inflammatory infiltrate, mainly eosinophilic, edema and nematode larvae, referable to Anisakis, surrounded by necrotic-inflammatory material. Moreover, there was evidence of giant a Meckel's diverticulum. DISCUSSION: Normally, enteric anisakiasis exhibits leukocytosis with eosinophilia and high CRP levels. There are cases of successful medical treatment and other cases of endoscopic treatment avoiding surgical procedure. In our case, enteric Anisakias had not been taken into consideration at the moment of the operation and only histopathology could reveal Anisakis larvae inside the intestinal wall. CONCLUSION: Our surgical approach is considered in literature as the best one for this clinical presentation. Those patients need to be better studied and more attention should be paid to their history.

Imaging visceral adhesion to polymeric mesh using pneumoperitoneal-MRI in an experimental rat model.

BACKGROUND: Intraperitoneal mesh implantation is often associated with formation of adhesion to the mesh. This experimental study examines the potential of minimally invasive pneumoperitoneal-MRI to assess these adhesions in a preclinical context. METHODS: Uncoated polyethylene terephthalate meshes were placed intraperitoneally in rats, in regard to the caecum previously scraped to promote petechial bleeding and subsequent adhesions. Examinations were performed 2-weeks post mesh implantation using a rodent dedicated high field MRI. Respiratory-triggered T2-weighted images were acquired prior to and after intraperitoneal injection of ~8-10 mL gas to induce a mechanical stress on the abdominal wall. RESULTS: Adhesions are occasionally seen in sham-operated rats as opposed to rats receiving polyethylene terephthalate meshes. On high-resolution images, meshes can be detected due to their characteristic net shape. However, evidence of adherence is only found if intraperitoneal gas injection is performed, when a ~1-cm elevation of the abdominal wall is observed. When adherence occurs between the mesh and the caecum, the latter remains in contact with the wall. Looser adherences between visceral tissue and meshes are also observed. CONCLUSIONS: T2-weighted pneumoperitoneal-MRI is a powerful tool for assessing adherence after intraperitoneal mesh implantation. According to the mini-invasive procedure adopted here, this approach may allow a temporal follow-up of adherence fate.

Appendiceal adhesion to synthetic mesh after laparoscopic sacrocolpopexy: a case report.

Minimally invasive alternatives to abdominal sacrocolpopexy have been shown to be equivalent with low overall complication rates. A small number of direct mesh-related gastrointestinal complications have been reported in the literature. Sacrocolpopexy with mesh retroperitonealization is recommended to minimize bowel adhesions. A 53-year-old nulligravid woman presented with persistent right lower-quadrant pain 1 year after laparoscopic sacrocolpopexy. The polypropylene mesh used during the case was retroperitonealized. Computed tomography (CT) prior to surgical exploration revealed no obvious pathology. On diagnostic laparoscopy, appendiceal adhesion to mesh requiring an appendectomy was observed. The patient's symptoms resolved after surgical intervention. Appendiceal adhesion to surgical mesh leading to chronic discomfort is a potential complication of intraperitoneal synthetic mesh placement. Our case emphasizes that bowel adhesions may occur even after proper mesh retroperitonealization. Appendiceal adhesion to the surgical site is a potential complication of retroperitonealized synthetic mesh placement at the time of sacrocolpopexy.